Quarterly Pharmacy Changes Effective April 1, 2020

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2020 – Part 1

DRUG LIST CHANGES Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) will be made to the Blue Cross and Blue Shield of Texas (BCBSTX) drug lists. Your patient(s) may ask you about therapeutic or lower cost alternatives if their medication is affected by one of these changes. Changes effective April 1, 2020, are outlined below.

The Quarterly Pharmacy Changes Part 2 article with more recent coverage additions will also be published closer to the April 1 effective date.

Please note: The drug list changes listed below apply only to some members whose health plan’s prescription drug list has moved to quarterly updates. BCBSTX members on the Basic Annual, Multi-Tier Basic Annual, Enhanced Annual, Multi-Tier Enhanced Annual or Performance Annual Drug Lists will not have the revisions and/or exclusions applied until on or after Jan. 1, 2021.

Drug List Updates (Revisions/Exclusions) – As of April 1, 2020

Non-Preferred Brand1 Drug Class/ Preferred Generic Preferred Brand Condition Used Alternative(s)2 Alternative(s)1, 2 For Basic, Multi-Tier Basic, Enhanced, Multi-Tier Enhanced Drug Lists Revisions EPIPEN-JR 2-PAK Anaphylaxis Generic equivalent available. Members should talk (epinephrine solution to their doctor or pharmacist about other auto-injector 0.15 medication(s) available for their condition. mg/0.3 ml (1:2000)) MORPHINE SULFATE Pain Generic equivalent available. Members should talk (morphine sulfate tab 15 to their doctor or pharmacist about other mg, 30 mg) medication(s) available for their condition. NOXAFIL Fungal Infections Generic equivalent available. Members should talk (posaconazole tab to their doctor or pharmacist about other delayed release 100 mg) medication(s) available for their condition. TRACLEER (bosentan Pulmonary Arterial Generic equivalent available. Members should talk tab 62.5 mg, 125 mg) Hypertension to their doctor or pharmacist about other medication(s) available for their condition.

Basic and Multi-Tier Basic Drug Lists Revisions DELZICOL (mesalamine Ulcerative Colitis, Generic equivalent available. Members should talk cap dr 400 mg) Proctitis to their doctor or pharmacist about other medication(s) available for their condition. LOTEMAX (loteprednol Ocular Generic equivalent available. Members should talk etabonate ophth susp Pain/Inflammation to their doctor or pharmacist about other 0.5%) medication(s) available for their condition. LYRICA (pregabalin cap Diabetic Generic equivalent available. Members should talk 25 mg, 50 mg, 75 mg, Neuropathy, to their doctor or pharmacist about other 100 mg, 150 mg, 200 Neuropathic pain, medication(s) available for their condition. mg, 225 mg, 300 mg) Fibromyalgia

Page 1

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2020 – Part 1 (cont.)

Drug1 Drug Preferred Alternative(s)1,2 Class/Condition Used For Balanced, Performance and Performance Select Drug Lists Revisions ALENDRONATE SODIUM Osteoporosis alendronate 35 mg tablet, ibandronate (alendronate sodium tab 5 mg) tablet, risedronate tablet CHLOROTHIAZIDE Edema, Heart Failure, chlorthalidone tablet, hydrochlorothiazide (chlorothiazide tab 500 mg) Hypertension tablet NITROGLYCERIN ER Angina, Heart Failure, isosorbide dinitrate tablet, isosorbide (nitroglycerin cap er 6.5 mg, 9 Hypertension mononitrate tablet mg) NITRO-TIME (nitroglycerin cap er Angina, Heart Failure, isosorbide dinitrate tablet, isosorbide 6.5 mg, 9 mg) Hypertension mononitrate tablet OXAZEPAM (oxazepam cap 15 Anxiety lorazepam tablet, temazepam capsule mg) OXYCODONE/ASPIRIN Pain oxycodone tablet, (oxycodone-aspirin tab 4.8355- oxycodone/acetaminophen tablet 325 mg) PROMETHAZINE/ Cough Members should talk to their doctor or DEXTROMETHORPHAN pharmacist about other medication(s) (promethazine-dm syrup 6.25-15 available for their condition. mg/5 ml) PROMETHAZINE-DM Cough Members should talk to their doctor or (promethazine-dm syrup 6.25-15 pharmacist about other medication(s) mg/5 ml) available for their condition. SELEGILINE HCL (selegiline hcl Parkinson's Disease selegiline capsule tab 5 mg) THEOCHRON (theophylline tab Asthma, COPD, Members should talk to their doctor or er 12hr 100 mg, 12hr 200 mg) Emphysema, pharmacist about other medication(s) Bronchitis available for their condition. THEOPHYLLINE ER Asthma, COPD, Members should talk to their doctor or (theophylline tab er 12hr 450 mg) Emphysema, pharmacist about other medication(s) Bronchitis available for their condition.

Balanced Drug List Revisions CARBINOXAMINE MALEATE Symptoms of carbinoxamine 4 mg tablet (carbinoxamine maleate tab 6 Seasonal or Perennial mg) Allergic Rhinitis RYVENT (carbinoxamine maleate Symptoms of carbinoxamine 4 mg tablet tab 6 mg) Seasonal or Perennial Allergic Rhinitis

Page 2 Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2020 – Part 1 (cont.)

Drug1 Drug Preferred Alternative(s)1,2 Class/Condition Used For Balanced, Performance and Performance Select Drug Lists Exclusions DYRENIUM (triamterene cap 50 Heart Failure, Edema Generic equivalent available. Members mg, 100 mg) should talk to their doctor or pharmacist about other medication(s) available for their condition. FIRAZYR (icatibant acetate inj 30 Hereditary Generic equivalent available. Members mg/3 ml (base equivalent)) Angioedema should talk to their doctor or pharmacist about other medication(s) available for their condition. LYRICA (pregabalin cap 25 mg, Diabetic Neuropathy, Generic equivalent available. Members 50 mg, 75 mg, 100 mg, 150 mg, Fibromyalgia, should talk to their doctor or pharmacist 200 mg, 225 mg, 300 mg) Seizures about other medication(s) available for their condition. LYRICA (pregabalin soln 20 Diabetic Neuropathy, Generic equivalent available. Members mg/ml) Fibromyalgia, should talk to their doctor or pharmacist Seizures about other medication(s) available for their condition. MORPHINE SULFATE (morphine Pain Generic equivalent available. Members sulfate tab 15 mg, 30 mg) should talk to their doctor or pharmacist about other medication(s) available for their condition. NOXAFIL (posaconazole tab Fungal Infections Generic equivalent available. Members delayed release 100 mg) should talk to their doctor or pharmacist about other medication(s) available for their condition. TRANSDERM SCOP Nausea/Vomiting, Generic equivalent available. Members (scopolamine td patch 72hr 1 Motion Sickness should talk to their doctor or pharmacist mg/3 days) about other medication(s) available for their condition.

Balanced and Performance Select Drug Lists Exclusions DICLEGIS (doxylamine- Nausea/Vomiting of Generic equivalent available. Members pyridoxine tab delayed release Pregnancy should talk to their doctor or pharmacist 10-10 mg) about other medication(s) available for their condition. EPIPEN-JR 2-PAK (epinephrine Anaphylaxis Generic equivalent available. Members solution auto-injector 0.15 mg/0.3 should talk to their doctor or pharmacist ml (1:2000)) about other medication(s) available for their condition.

Performance and Performance Select Drug Lists Exclusions desoximetasone gel 0.05% Dermatitis, betamethasone dipropionate 0.05 % Inflammatory augmented cream, betamethasone Conditions dipropionate 0.05 % ointment triamcinolone acetonide aerosol Inflammatory triamcinolone acetonide 0.1% ointment, soln 0.147 mg/gm Conditions triamcinolone acetonide 0.1% cream

Page 3 Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2020 – Part 1 (cont.)

Drug1 Drug Preferred Alternative(s)1,2 Class/Condition Used For Balanced Drug List Exclusions BUPRENORPHINE Pain Belbuca (buprenorphine td patch weekly 5 mcg/hr, 10 mcg/hr, 15 mcg/hr, 20 mcg/hr) buprenorphine td patch weekly 5 Pain Belbuca mcg/hr, 10 mcg/hr, 15 mcg/hr, 20 mcg/hr) BUTRANS (buprenorphine td Pain Belbuca patch weekly 7.5 mcg/hr) HALOG (halcinonide cream Dermatitis, Generic equivalent available. Members 0.1%) Inflammatory should talk to their doctor or pharmacist Conditions about other medication(s) available for their condition.

1Third-party brand names are the property of their respective owner. 2This list is not all inclusive. Other medicines may be available in this drug class.

DISPENSING LIMIT CHANGES The BCBSTX prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on U.S. Food and Drug Administration (FDA) approved dosage regimens and product labeling. Changes by drug list are listed on the charts below. Please note: The dispensing limits listed below only apply to select members whose plan has moved to quarterly updates on their prescription drug list. BCBSTX members on an annually updated prescription drug list will have these dispensing limits applied on or after Jan. 1, 2021.

Effective April 1, 2020:

Drug Class and Medication(s)1 Dispensing Limit(s) Basic, Enhanced, Balanced, Performance, Performance Select Drug Lists Androgens and Anabolic Steroids Android 10 mg 600 capsules per 30 days Androxy 10 mg 120 tablets per 30 days Methitest 10 mg 600 capsules per 30 days Methyltestosterone 10 mg 600 capsules per 30 days Testred 10 mg 600 capsules per 30 days Biologic Immunomodulators Xeljanz 10 mg 224 tabs per 365 days

Basic and Enhanced Drug Lists Sunosi Sunosi 75 mg 30 tablets per 30 days Sunosi 150 mg 30 tablets per 30 days

1Third-party brand names are the property of their respective owner.

Page 4 Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2020 – Part 1 (cont.)

UTILIZATION MANAGEMENT PROGRAM CHANGES  Effective Nov. 15, 2019, generic Elidel was added as a target to the Atopic Dermatitis Step Therapy Program, which applies to the Basic, Basic Annual, Enhanced, Enhanced Annual, Performance and Performance Annual Drug Lists.  Effective Jan. 1, 2020, the Sunosi Prior Authorization (PA) program was added to the Balanced, Performance, Performance Annual, Performance Select and Performance Select Annual Drug Lists.* This program includes the target drug Sunosi.  Effective Feb. 1, 2020, the following changes were applied: o The Idiopathic Pulmonary Fibrosis (IPF) PA program changed its name to Interstitial Lung Disease (ILD). This PA program includes the same targeted medications, Esbriet and Ofev. This program currently applies to the Basic, Basic Annual, Enhanced, Enhanced Annual, Performance, Performance Annual, Performance Select and Performance Select Annual Drug Lists. o The hATTR Amyloidosis Neuropathy and the Tafamidis PA programs combined to form one new standard PA program. The new ATTR Amyloidosis PA program includes the same target drugs: Tegsedi, Vyndaqel and Vyndamax. This program currently applies to the Basic, Basic Annual, Enhanced, Enhanced Annual, Performance, Performance Annual, Performance Select and Performance Select Annual Drug Lists.  Effective April 1, 2020, several drug categories and/or targeted medications will be added to the PA programs for standard pharmacy benefit plans, upon renewal for most members. As a reminder, please review your patient’s drug list for the indicator listed in the Prior Authorization or Step Therapy column, as not all programs may apply, Additionally, please be sure to submit the specific prior authorization form for the medication being prescribed to your patient.

Members were notified about the PA standard program changes listed in the tables below.

Drug categories added to current pharmacy PA standard programs, effective April 1, 2020, ** Drug Category Targeted Medication(s)1 Basic and Enhanced Drug Lists Sunosi Sunosi

1Third-party brand names are the property of their respective owner. * Not all members may have been notified due to limited utilization. ** Applies to select members April 1, 2020. Members on an Annual drug list may not see these changes applied until their renewal date

Per our usual process of member notification before implementation, targeted mailings were sent to members affected by drug list revisions and/or exclusions, dispensing limit and prior authorization program changes. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of our Provider website.

If your patients have any questions about their pharmacy benefits, please advise them to contact the number on their member ID card. Members may also visit bcbstx.com and log in to Blue Access for MembersSM (BAMSM) or MyPrime.com for a variety of online resources.

Page 5 Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2020 – Part 1 (cont.)

Reminder: Drug Coupon Change Drug manufacturer coupons (or copay cards) used by members for specialty and non-specialty drugs will not count toward the deductible (if applicable) and/or annual out-of-pocket maximum effective on or after Jan. 1, 2020. This change applies to most BCBSTX members with a group health plan, though some exceptions may apply.

Letters were sent in January to members who have been identified as using a drug coupon. Please call the number on the member’s ID card to verify coverage, or for further assistance or clarification on your patient’s benefits.

Insulin Aspart Covered on Select Drug Lists Starting Dec. 15, 2019, Insulin Aspart vials and pens will be added to the preferred brand tier, the same tier as the brand Novolog, on the Basic, Basic Annual, Enhanced, Enhanced Annual, Performance and Performance Annual Drug Lists.** This change applies to BCBSTX members, who have prescription drug benefits administered by Prime Therapeutics. Insulin Aspart is also known as NovoLog® and NovoLog® Mix authorized generics or follow on brands.

Insulin Aspart will be excluded from coverage on the Balanced and Performance Select Drug Lists. The brand Novolog will remain covered on these drug lists. Only members with a coinsurance or high deductible health plan, based on the member’s benefit plan, may see a cost share reduction based on the authorized generic price.

**Insulin Aspart is covered as a non-preferred generic on the Health Insurance Marketplace Drug List.

Please call the number on the member’s ID card to verify coverage.

Pharmaceutical Care Management BCBSTX ‘s Pharmaceutical Care Management (PCM) team routinely reviews medication claims to identify members who may benefit from further review for possible drug therapy issue(s) or to address any cost concerns for members. This review service is part of the PCM program, which also provides members access to clinical pharmacists and other resource tools to help answer questions they may have about their prescriptions. The goal of the PCM program is to ensure patients’ medications are safe, appropriate and effective.

If your patient is identified for this further review, you may receive a request from our PCM team to provide more clinical information for evaluation. You will also be engaged with your patient and one of our clinical pharmacists through each step of this review and the recommended action plan. We encourage you to please review the action plan and talk with your patient as you think appropriate to optimize therapy.

Additionally, PCM pharmacists and technicians may reach out to advise providers if patients may be affected by an upcoming drug list (formulary) change or if a medication has a new prior authorization requirement. Please Note: This type of support is based on the member’s benefit plan and not available for all members.

Performance Select Annual Drug List Retiring On April 1, 2020, the Performance Select Annual Drug List will be retired. All members on this drug list will have moved to the quarterly Performance Select Drug List. As previously communicated throughout 2019, most of the prescription drug lists that were once updated annually Jan. 1, or at the group’s renewal date, have moved to a quarterly update. The final implementation of the drug list update frequency change occurs in the first quarter of 2020, on or after Jan. 1, 2020.

Page 6 Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2020 – Part 1 (cont.)

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSTX contracts with Prime to provide pharmacy benefit management and related other services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. MyPrime.com is an online resource offered by Prime Therapeutics.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.

Page 7